Multiple substance use by HIV status among United States adults, 2021–2024

Background Substance use is common among people with HIV (PWH) and is associated with lower antiretroviral therapy adherence, poorer HIV outcomes, and negative health consequences. PWH are more likely to use substances than the general population; however, less is known about multiple substance use, which is important as it might have greater negative effects for PWH (e.g., decreased life expectancy, negative mental health symptoms) than single substance use. This study examined the differences in the number of substances used by HIV status among United States (US) adults. Methods We analyzed pooled data from the 2021–2024 National Survey of Drug Use and Health ( N = 186,823; 51.3% female, 61.3% non-Hispanic White). Multivariable Poisson regression models examined associations between self-reported lifetime HIV diagnosis (predictor) and number of substances used in the past month (outcome), adjusting for covariates. Results PWH reported a greater number of substances used in the past month compared to adults without HIV (adjusted prevalence ratio [APR] = 1.60; 95% confidence interval [CI]: 1.38–1.85). This association remained significant among individuals reporting any substance use (APR = 1.27, 95% CI = 1.13, 1.43) and among those reporting polysubstance use (2 or more substances) (APR = 1.15, 95% CI = 1.06, 1.24). Among PWH, the most common patterns were alcohol only, alcohol plus tobacco, and alcohol plus tobacco plus cannabis. Conclusions PWH are more likely to engage in multiple substance use than adults without HIV, supporting the integration of substance use assessment, education, and treatment referrals into HIV care.